Healthcare Provider Details

I. General information

NPI: 1528986940
Provider Name (Legal Business Name): MIA KIMIKO DESOTO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 PENNSYLVANIA AVE STE 230
FAIRFIELD CA
94533-3550
US

IV. Provider business mailing address

313 SHAKER DR
VACAVILLE CA
95687-8022
US

V. Phone/Fax

Practice location:
  • Phone: 707-646-4370
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95038894
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: